Birth: The system is broken if it doesn't leave people whole

When I was just getting started with this birthing thing I was pretty enthusiastic. I did a lot of reading. I wrote optimistic essays about birthing choices for my shockingly bad website. I tried to be a doula, though I’m not sure I was ever a particularly good one. I went to conferences and training days by the dozen. I believed that I could make a difference. I believed that positive change was inevitable, that the facts were lining up and soon everyone would have to agree on the appropriate approach. All we had to do was be firm, keep tabulating research, and make it available. Wait the change out and it would happen.

But as I say, I was a perhaps not very good doula, and in the main the births I ended up attending were those of strangers, often strangers that I hadn’t met before I found them in the labour and delivery room at a local hospital (ah, the free referral service of the local doula organization), and by the time I got there things were already on their downward spiral. The induction was on and it was only a matter of time before someone became exhausted and bored and suggested a c-section. Hapless women of colour with poor English and their equally hapless husbands and partners were funnelled through to the operating room and for all my enthusiastic soothing and panting and rocking and walking and changing positions there was nothing I could do to change it.

In all the births I attended at that time, there were only two decent ones, one a homebirth, the other a hospital birth, older white mothers full of determination. They knew what they wanted. They fought for it, and they were very clear about what they wanted from me. So, it worked, you see. They had the education, experience, determination and white privilege to get what they wanted, a birth that wasn’t abusive or horrible. It certainly helped that they were women having second babies, as second babies are always more responsive to the arbitrary timelines of the medical model. It was a gift to be their doula, it really was.

In between births I did postpartum doula work, some volunteer, some for a pretty good wage. Here too I could see how damaging the medical model was. One young woman I was helping for free was in Canada alone, her husband in Malaysia waiting on his visa application. She’d given birth alone, a young non-white woman with no apparent partner and poor English. She’d had a good nurse, she felt, but the doctor, a woman, was rough and impatient with her, and had performed an episiotomy that resulted in a fourth degree tear, very painful and with a difficult and perhaps surgical recovery.

Another woman I served for a few weeks, helping out through the nights, had been pregnant with twins. Her babies were delivered via c-section, for no other reason than that they were twins. She was struggling with the continuing pain of her incision, not being able to breastfeed her son, who wouldn’t latch and would only take a bottle, and pumping around the clock to supply them both with breastmilk. She was exhausted.

Another woman was in Canada from England, but was not yet covered by health benefits. The doctor she saw would not permit her to attempt a trial of labour after her previous c-section, so she was forced to undergo another surgery and pay for the entire thing out of pocket as well.

I was called to help with breastfeeding with another older couple, who gave birth at home with registered midwives. She had a tear which required stitching and while the midwives were stitching it up they kept the baby in another room away from her. For an hour and a half. The first time she tried to breastfeed after her birth her baby was already through its wide awake period and slept instead. Two days later, still not nursing.

All of this is a very long-winded way of saying that after a few months of thinking about birth! and babies! with stars in my eyes! and then attending a weekend workshop in which women imagined awesome births and inspirational stories were told by the doula instructors of how they had saved women’s births and so on, I somehow plunged headfirst into the deep end of how awful and how broken the medical model of birth really is.

Statistics

I’m making this all sound a little grim, that’s because it is a grim business and the statistics bear that out. In British Columbia (BC), where I live, the current c-section rate is over 30%. It’s not a stretch to suggest that for every three women who give birth in this province, one will end up with major abdominal surgery. This is not a supportable rate. The World Health Organization recommends that a reasonable c-section rate should be no more than 10-15%, and this rate has been shown repeatedly to produce the best outcomes for mothers and babies.

Now if a reasonable rate with the best outcomes is 10-15% and our current rate is over 30% then 15-20% of birthing women are having unnecessary surgery.

Let me repeat that.

The medical model of birth as practiced in British Columbia (and the rest of Canada and much of the United States) results in 15-20% of all birthing women, perhaps as many as 1 in 5, having unnecessary surgery. 50% or more of the c-sections performed do not improve outcomes for mothers and babies.

And of course, it’s not as though the women who are giving birth vaginally are getting off scott free in this system. They’re birthing under the ever present threat of major abdominal surgery, for one thing. Forceps and Vacuum extractor are used 3.4% and 6.3% of the time, so that means another 10% of women at the very least are having episiotomies and having their babies pulled out with varying degrees of skill. 45% of women have epidural anesthesia, which is certainly successful, most of the time, at blocking sensation, but also makes far more likely the perceived need for “augmentation” of labour, including artificial rupture of membranes and syntocinon augmentation - I couldn’t find a rate for syntocinon usage, but it tends to be fairly high, often as much as twice as high as the c-section rate. 21% of women in BC also have their labour artificially “induced”.

Women are having pretty awful birth experiences. Not universally, of course. But a lot of them.

I used to explain to people how the cascade of interventions worked, how one intervention would lead to another and then another, and how one simple bad decision on the decision tree could lead to a seemingly necessary (but really unnecessary) c-section. And in my explanation, I’d pile them on a little. My hypothetical birthing women experienced as much intervention as I could believably throw at them in order to demonstrate the point.

And people were a little disbelieving. Who could blame them? It does seem a little outrageous that doctors, who are in the main probably well-meaning people, could end up performing unnecessary major abdominal surgery on one fifth to a quarter of their healthy birthing patients.

But the problem with my hypothetical is I saw it played out or heard about it played out in almost exactly the ways I’d described far too many times. It wasn’t just an illustrative fiction, it was a common reality.

Illustrative Non-Fiction

The last birth I went to as a doula was for an aboriginal woman and her husband who had been referred by a friend of a friend. I met them, literally, outside the hospital’s door when they were going in for an induction. She was only 38 weeks pregnant, but was diabetic and her doctor was quite concerned that her baby would be enormous. “Huge, 10 pounds at least!” was the way it was quoted to me.

She was pretty chilled out about being induced early, because with her previous child, now an active three-year-old, she had been induced at 38 weeks as well. 10 hours later she was holding her vaginally birthed baby in her arms. Hard to argue with that record of success, and although I suggested that perhaps waiting at least another week would be a good idea, big baby or no, I could see that this idea was falling on deaf ears. I didn’t say much.

She went in for her induction in the evening and they gave her prostaglandin gel applied to her cervix. Her cervix was “unfavourable”, which is to say, nowhere near ready for giving birth, but the induction happened anyway. By 1 a.m. she was having frequent sensations and was throwing up - often a good sign of progress in birthing. This continued through the night. Her husband wouldn’t lie down and sleep for an hour to remain rested, so when morning came they was pretty exhausted, but they were both convinced that things must be going swimmingly and the birth would be soon.

The OB-of-the-day arrived and checked her and her cervix was as it was before, not dilated at all, not effaced, still posterior. Still, in other words, unfavourable. But still, her sensations were still frequent, and so the doctor started her on syntocinon. The sensations became more uncomfortable and during one when she was moaning through the sensation a nurse poked her head in the door and said, “You look like you’re in pain. I’ll get you some pethidine.” She came back and put it in the IV, I think. This, by the way, is an excellent example of the kind of “informed consent” that is often demonstrated in hospital births. She wasn’t asked whether she wanted it. She wasn’t even asked if she was in pain or suffering. She wasn’t presented it as an option with these pros and these cons. It was just given to her.

Once the syntocinon was started, of course, external fetal monitoring was put on next. The contraction monitor worked consistently, but the baby, as babies pretty consistently do, kept moving around and the monitor would no longer be correctly placed so that the nurse would come in and fuss with the monitor, get the baby heart swooshing away on the speaker again and then bustle off, only to repeat the scene five or ten minutes later. She dozed with the pethidine for quite a while, not even feeling her contractions any more and her husband and I dozed too in uncomfortable upright chairs against the wall.

The OB-of-the-day kept coming in and telling the nurse, who had already been upping the syntocinon on schedule, to up it some more. At one point the nurse said, “We’re already at the limit that we’re supposed to use for an induction.”

The OB replied, “This is an augmentation, not an induction. Up it some more.” The nurse bit her tongue and did as she was told.

Every time she was checked her cervix was unchanged. Or no, a little changed. Effaced (thinned) to two fingers instead of three, still not dilated at all, but perhaps less posterior. This was considered to be progress.

Finally, after 24 hours from the first prostaglandin gel and about 2 hours before the OB-of-the-day was supposed to end her shift, the OB came and inspected the situation.

The baby was healthy as a horse, moving around, repeatedly bashing and kicking at the monitor, strong heart rate throughout, so they couldn’t use fetal distress as their reason for a c-section.

For some reason (because her cervix never dilated much most likely) they had never gotten around to rupturing her membranes, so they didn’t have that artificial timeline on their side, something to point to with assurance for why they needed to do a c-section.

Since she’d had a previous large baby vaginally it would be very difficult to argue cephalopelvic disproportion (where the pelvis is too small or narrow to allow the passage of the baby’s head).

And of course, they couldn’t just let her go home, say, “Oops, our mistake, your body wasn’t ready.” Not with that enormous ten pound baby inside.

Nope, they needed an ironclad irrefutable reason to cut this woman’s belly open. So they told her her baby was breech.

How big was that baby, do you think? 7 pounds, 3 ounces. And showing signs of prematurity. And sleepy, oh so sleepy, wouldn’t get on the boob and nurse, not for days and days and days. I lost track of them when she went home to her active three-year-old with her belly cut open.

It’s not like I did them any good. And while, as I say, I kind of suspect I just really wasn’t very good at this doula thing, I’m not sure that another doula could have improved things, prevented the outcome. I realized that as a doula I didn’t have any power to change the system. I might be able to occasionally help a woman emotionally or practically, but I would be witness to so much abuse. I stopped going to births as a doula.

The more things don't change ...

I didn’t stop being interested. I hung around with a lot of unassisted birthers online. I didn’t stop reading or following research. The evidence for less interventions or for only appropriate usage of interventions keeps piling up, they reversed the prohibition on “allowing” women to go past 41 weeks without inducing them, a Vancouver doctor did a massive study on episiotomy and proved once and for all how useless and dangerous it was and the rate actually dropped, there are positive changes.

At the same time, the rate of positive change is very very slow, and it often seems like for every one step forward there’s half a step back and one step off in a complete other non-helpful direction. I’ve been witness to two births in the last couple of months, one a homebirth and one a very interventionalist hospital birth. It was night and day between the two.

The homebirth was a VBAC and resulted in a home waterbirth to a beautiful baby. This was after the mother was told she couldn’t possibly have a homebirth after a previous cesarean. She then asked her care providers whether she could at least labour in a tub of water in the hospital and was told that of course she couldn’t. Irrirtated at being undermined at every turn in her very reasonable and safe wishes for her birth, she sought out a traditional birth attendant who had no problem facilitating her (safe) homebirth.

The hospital birth was of a young woman having her first baby with registered midwives as her caregivers. It was truly shocking to me. It was as though someone had brought to life my old story of the cascade of interventions. The fact that the birth ended in a c-section was all so unnecessary, every step along the way so unsupported by the available research.

It’s sometimes mind-boggling that as a birthing community, in which I include doctors, midwives, doulas, OBs, pregnant women and partners and all the rest, we can know the right things to do or not do. We can have the research in front of us, from well-executed and documented studies and trials and we can have it for years with every new study backing it up, and yet the reality of the abuses that occur in mainstream birthing all in opposition to what we know continue. Does spontaneous, uninterfered with birth just not have a great marketing department? I don’ t know, and I sometimes feel very discouraged.

The system is broken. What next?

But then, I’m kind of an optimist. Or perhaps the better word would be idealist, although I think we are wrong as a society to say “idealist” with the kind of sneer. If we do not ask for and strive for the ideal then we’ll never come close. Asking for a compromised position right off the bat means that the eventual product will inevitably be even more compromised (just look at the current American health care debate for a prime example of that).

As I said before, I don’t believe that all or even most doctors and registered midwives are evil people looking for the quickest and most painful way to hurt people. That’s ridiculous. Of course most of them are caring and well-meaning people. I say that even though I’ve witnessed quite a few fairly ignorant or arrogant people in the field, one or two exceptionally abusive and manipulative individuals, and rather a lot of folks who exhibit that passive “just following orders/my protocols/our customs” well-intentioned uselessness.

But the problem is this. The system is broken. It did not and does not have women’s best interests or the best interests of their babies at heart. It is a fraud.

A 30% c-section rate (and a 19% primary c-section rate) is not a bug, it is a feature of the broken system.

That some women would choose to give birth unassisted because they fear what they will experience otherwise at the hands of the medical system, this is also a feature. Unassisted birthers can be used by the mainstream model to make homebirth seem extreme and outlandish, something that only those crazy hippies or religious fundamentalists would do. I say that as someone who chose to give birth unassisted, and who feels that this can be an awesome valid choice for some folks, but that it should never feel like the only choice available.

When I say that I believe people are well-intentioned, I should also say that it’s time for folks to face the fact that intentions really don’t matter. Or at best they matter only a little bit. What matters is not what you intend, it is what you do. It is the real results of your actions in real people’s lives. If you as a provider through your action or inaction facilitate 20% of of your clients right into unnecessary surgery with very real and significant impacts on their life, health, future fertility and reproduction and on their future children’s life, health and births, but you meant well, it doesn’t reverse the effects. It doesn’t change the real effects that a caesarean scar on her uterus and belly produce.

It seems to me that with a system as broken as this there are only two ethical choices. The first is the actively try to fix the system from the inside. The second is to work outside the system to provide another option for women. I suppose, now I think of it, that there’s a third ethical choice, which is get out of this business entirely. Passively continuing within the system, acting in such a way that you perpetuate the harm that it does, this is not an ethical choice.

I’ll be honest, I’m not sure if it is possible to fix the broken system from the inside, but if you are a care provider within the medical model, there’s a lot you can do to try. Here’s a few suggestions:

Practice research-based care.

Accept that women are individuals, their bodies are individual, and there is a wide range of normal.

If a rule is a bad rule, don’t follow it.

Don’t induce women at 38 weeks, at 39 weeks, at 40 weeks, at 41 weeks, at 42 weeks because you’re pretty sure she should give birth by now.

Actually, don’t induce them at all if you can help it. Women will, for the most part, go into labour spontaneously when they and their baby/ies are ready.

Don’t hold the threat of induction over their head, ever. “If you don’t go into labour by 42 weeks, we’re not allowed to do a homebirth.”

Don’t encourage women to induce “naturally”. We do not know exactly causes labour to start spontaneously, but we know that it seems to be a combination of factors regarding readiness for both mother and child. Knowing that, it seems foolish to think that a “natural” induction would be any less dangerous than an “unnatural” one. I would suggest that there is no such thing as a “natural” induction.

Actively encourage home birth for all women, low and high risk, since this is actually supported by research. Don’t force it, of course, but assume as a matter of course that this is where birth occurs. Research has shown repeatedly that hospital birth is not as safe as home birth.

If a woman prefers a hospital birth, do not admit her to the hospital before she is in active labour (4 cms).

Do very few cervical checks. Do none if you can manage it. Learn to gauge the progress of her labour using other less interventive signs.

Intermittently monitor the fetal heart rate with a stethoscope instead of using continuous electronic fetal monitoring.

Accept that it is not uncommon and not pathological for labour to proceed in a less than straight ahead fashion. Pauses and breaks in labour are actually quite common and don’t mean the process is broken and needs fixing.

Learn about non-narcotic comfort measures for women in labour.

Accept that there is a difference between pain and suffering, so that just because a woman is experiencing pain, that doesn’t mean she is suffering.

Accept that you don’t need to rescue women from their birthing process.

Learn to sit on your hands. A lot. Birth needs very little “doing”. If sitting on your hands isn’t a good option for you, learn to knit. Embroidery is probably another good option. Machine quilting might be a bit much.

Buy a good quality labour and birthing pool and make it available for your client’s births.

Don’t transfer women to the hospital or start otherwise intervening because of arbitrary time lines that have nothing to do with what is actually happening for her in her body. This includes long early labour, long active labour, long pushing stages, long periods with membranes released before the birth of the baby.

Use antibiotics responsively, not automatically.

Practice informed consent. Be able to articulate the benefits and problems inherent in the interventions you do offer or that clients request, so that nobody ever says, “if only someone had told me what this could do”.

If a woman has PROM (premature rupture of membranes), do no cervical checks at all. Be watchful for signs of infection and encourage good hydration and nutrition, but otherwise just be patient.

Talk a lot more about nutrition with your clients, since this is one of the only things actually shown by research to make a difference in the health of women and their babies.

Study methods to safely facilitate vaginal breech birth.

Keep mother and baby together in the period immediately following birth (out to a half an hour or more). They need each other.

Practice expectant management of the third stage of labour (delivery of the placenta).

Leave the cord intact until the placenta is delivered.

Foster friendships with likeminded individuals in your field. Have someone you can call when you think things aren’t going as they should.

If a cesarean is necessary, be as humane as possible. Don’t let a hospital’s rules get in the way.

Don’t be a martyr. Take good vacations. Get sleep at night. Spend time with your family. Birth work is unpredictable, but try to just live your life.

Take good naps at homebirths and eat good food. Nobody needs your attention 100% of the time, and it can be reassuring for women if her care providers remain relaxed and low key.

Get help to deal with stress. Foster positive relationships in your personal life.

Perhaps you already do some of these things. Perhaps these do not seem like workable suggestions to you. But if not, ask yourself why and own your answers. For an online discussion on this article visit Kenzie's Blog

Written January 22, 2010

This is an opinion piece written by Kenzie.

Kenzie is a slightly tyrannical and very opinionated long-time but lackadaisical blogger with an inappropriate fondness for adjectives and adverbs. Kenzie has also worked for many years as a doula, postpartum doula and breastfeeding counselor, though she has six opinions and a half about why that actually isn’t the best role she can play in the birthing community. So instead, lately she’s been an informal educator and advocate for homebirth and informed choice. Visit Kenzie's Blog